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Corresponding author. Department of Orthopaedic Surgery, Holy Cross Orthopedic Institute, 5597 North Dixie Highway, Fort Lauderdale, FL 33308, USA. Tel.: +1 954 542 4148.
The use of metal bearings in total hip arthroplasty (THA) has been linked with adverse local tissue reactions (ALTRs). There is 1 reported case of ALTR from a ceramic-on-ceramic (CoC) bearing and none that resulted in nerve compression. In this case, a 71-year-old man presented with an ALTR after a CoC THA that resulted in femoral nerve compression. An anterior approach was utilized to revise his THA, which resulted in nerve decompression and near-resolution of his preoperative symptoms. We conclude that CoC bearings may not be completely inert and can result in ALTRs and nerve compression.
The use of hard-on-hard bearings in total hip arthroplasty (THA) has been shown to have benefits including better stability, decreased wear rate, and greater longevity [
]. These bearings, such as metal-on-metal (MoM) and ceramic-on-ceramic (CoC), gained popularity due to the concern for polyethylene wear in metal-on-polyethylene (MoP) implants. Despite the elimination of the polyethylene particles, metal wear debris has also led to its own complications. The debris formed from MoM implants has led to both mechanically assisted crevice corrosion (MACC) and adverse local tissue reactions (ALTRs) [
]. There are only a few cases describing MACC or ALTRs after CoC THA, and there are no reported cases of such complications resulting in femoral nerve compression [
]. The purpose of this report is to present a distinctive case of ALTR in a CoC THA resulting in femoral nerve compression with sensory findings.
Case history
Patient informed consent was obtained for publication of this deidentified case report.
In July 2020, a 71-year-old male presented with left hip pain 13 years after a posterior-approach left THA. The patient’s medical history was significant for hyperlipidemia and deep vein thrombosis with pulmonary embolism for which he is on atorvastatin and rivaroxaban, respectively. The patient received a Stryker Trident titanium acetabular shell (Stryker, Kalamazoo, MI) with a titanium-backed third-generation Trident 0° alumina insert ceramic liner and a 32-mm alumina taper ceramic head. A Stryker Accolade TMZF (Stryker, Kalamazoo, MI) was used for the femoral component. The patient’s 6-week history of pain and simultaneous “squeaking” started after he flexed at the hip to retrieve a ball while playing pickleball. He also had associated sensory numbness in the anterior and anteromedial thigh with no history of trauma or falls. At presentation, he characterized his pain as sharp, intermittent, and nonradiating and rated it a 5/10 on the visual analog scale. His symptoms were alleviated with rest, while his numbness, fullness at the hip, and “squeaking” remained. He denied fever, chills, or recent or remote infections. Physical examination revealed full extension with 80° of flexion, 10° of internal rotation, 30° of external rotation, 30° of abduction, and 10° of adduction. The patient had a clinically stable left hip. He ambulated with a normal tandem gait without the use of an assistive device. His posterolateral hip incision was well-healed, and there was no palpable mass or swelling. He had pain with log roll and resisted hip flexion, and Flexion, Abduction and External Rotation and Flexion, Adduction, Internal Rotation tests were also positive. He had diminished sensation over the anterior aspect of the left thigh, but all other distributions were intact. The rest of the patient’s physical exam including a thorough spine examination was within normal limits.
Radiographs of the left hip and anterior-posterior pelvis demonstrated a well-fixed press-fit THA with a single-wedge taper femoral component consisting of a ceramic head articulating with a metal backed ceramic acetabular liner (Fig. 1). Using the Velys Hip Navigation system templating software (VELYS Hip Navigation; DePuy Synthes, West Palm Beach, FL), the acetabular inclination was found to be 33°, and the anteversion was 17°. The patient’s magnetic resonance images revealed a heterogenous mass along the anterior aspect of the hip from the psoas muscle up through the iliacus measuring 7 × 5 × 5 cm, which also extended into the pelvis (Fig. 2). Blood tests revealed a normal differential with a white blood cell count of 6.5 billion cells/mcl, and the sedimentation rate (9 mm/h) and C-reactive protein (1 mg/L) level were also within normal limits. Cobalt was not detected (0.0-0.9 ug/L), the chromium level was 0.6 ug/L (0.1-2.1 ug/L), and titanium levels <10.0 mg/mL (<10.0 mg/mL) were obtained, which were found to be within normal limits [
]. The diagnosis of failed left hip arthroplasty and compressive neuropathy of the left femoral nerve due to an ALTR was discussed with the patient, and the patient elected to undergo a revision of his left THA.
Figure 1An anterior-posterior radiograph of the pelvis showing a well-fixed press-fit total hip arthroplasty without any evidence of osteolysis, loosening, or complication.
Figure 2Coronal-sagittal short tau inversion recovery (STIR) (a) and axial STIR sequence (b) magnetic resonance imaging showing joint fluid and synovitis within the left hip pseudocapsule dehiscing anteriorly into a large complex, representative of an adverse local tissue reaction.
An anterior approach was utilized as it was thought to provide the best opportunity to simultaneously revise the hip and decompress the mass while reducing the risk of posterior instability given the measured acetabular anteversion. Intraoperatively, an 8-cm anterior hip incision was made and carried obliquely toward the fibular head. An anterior capsulotomy was performed, and normal appearing synovial fluid was encountered and sent for culture. We encountered some granulomatous tissue at the inferior capsule, but no discrete mass was identified. The anterior capsulotomy was carried out proximally, which revealed a large granulomatous mass that was excised off the pelvic brim and sent for permanent pathology evaluation and aerobic, anaerobic, fungal, and mycobacterial cultures (Fig. 3). The blunt dissection was directed medially, while palpating for the femoral pulse, which expressed copious amounts of brown granular tissue. An in situ dislocation of the ceramic head from the stem’s taper was performed. Upon inspection, the ceramic head showed evidence of stripe wear (Fig. 4). A curved osteotome and mallet were used to atraumatically remove the titanium-backed ceramic liner, which had no evidence of backside wear on the titanium insert (Fig. 5). The cup was found to be well-fixed, and the trunnion appeared intact and without corrosion. We debrided around the stem-femur interface to better evaluate the stem fixation and attempted to extract the femoral stem which was solidly fixed. There was no evidence of impingement of the stem from the raised acetabular liner, thus the femoral component was left in place. A 36 +3-mm head was tried, which was found to be stable. The final prosthesis was placed, utilizing a ceramic head, a polyethylene liner, and a titanium sleeve over the femoral neck. We applied a 10° lipped polyethylene liner posteriorly as the acetabular shell appeared to be inadequately anteverted (Fig. 6). The hip was reduced and found to be stable in all planes. A histologic analysis for the specimen demonstrated a fibrinous exudate intermixed with few macrophages and blood. Scattered foreign-body-type multinucleated giant cells were also found, and no synovial or periarticular soft tissue was identified.
Figure 4The removed ceramic components with evidence of stripe wear. The ceramic head has a small “v”-shaped mark that resulted from intraoperative dislocation.
The patient’s postoperative course was uneventful, and the patient was made full-weight-bearing without hip precautions. The patient noted a mild improvement in the numbness over the anterior aspect of his thigh, immediately after the surgery, and had no further complications. His intraoperative synovial analysis demonstrated 4300 white blood cells, with polymorphonuclear cells forming 54% of the total. All cultures were negative after 8 weeks. At 3 months postoperatively, the patient was walking without an assistive device, had no pain, and minimal numbness at the thigh which significantly improved from the presurgical level.
One year following his revision surgery, the patient stated that he had no pain, his thigh numbness had completely resolved, and he was highly active returning to playing pickleball. His paresthesia and neuralgia from femoral nerve compression seemed to have been resolved, and he was very satisfied with the results of his surgery and alleviation of his symptoms. Unfortunately, at this time, the patient stated he had fallen while walking to his kitchen in the dark and sustained a Vancouver B2 periprosthetic femur fracture for which he underwent a revision surgery. Due to transportation and insurance issues, the patient was unable to return to the original surgeon and subsequently underwent the revision surgery and fixation of the fracture with an orthopedic surgeon at his local hospital. The operative report was obtained which stated that upon inspection, the acetabular cup was well-fixed, but the femoral component was grossly loose. A diaphyseal engaging modular revision stem of size 20 × 190 mm was used, with an 80-mm proximal body and 2 cerclage cables around the fracture site. A 36 +6 head was placed, and the hip was reduced, showing excellent stability and range of motion.
Discussion
In the literature, there are multiple reported cases of ALTRs and MACC after MoM and MoP THAs. An ALTR from a CoC THA, however, is rare, with only a few reported cases. Campbell et al. reported ALTR from a CoC THA in a 54-year-old female who presented with a painful postoperative hip [
]. The patient had their THA revised, and it was subsequently concluded that ceramic wear debris may have led to an ALTR due to the lack of metal debris and elevation of either the chromium or cobalt level [
]. Their case indicated that a prominent screw head caused abrasive backside liner wear and that ceramic liner malpositioning as well as liner locking failure led to liner fragmentation and loss of its taper fit that resulted in an ALTR [
]. In addition, further review of the literature revealed only a few cases of femoral neuropathy due to ALTR, and all of them developed after using MoM or MoP bearing surfaces. This is the first reported case, to our knowledge, where a patient developed femoral nerve compression from an ALTR after a CoC THA [
Growth of an intrapelvic pseudotumor associated with a metal-on-metal total hip arthroplasty after revision arthroplasty causing a femoral nerve neuropathy.
]. However, unique failure modes such as MACC and ALTRs became a great concern. This reaction can lead to bursal soft-tissue growth and result in dysfunction, pain, and neuropathy [
]. Impact load stress from the separation of the femoral head bearing surface and the acetabular component can also lead to damage. Additionally, the tensile stress produced from the potential hoop stress between the Morse taper trunnion and ceramic head also contributes. Although wear can occur, advancements in ceramic manufacturing have led to low incidences (0.01%-0.15%) of fracture in comparison to earlier-generation ceramics [
]. Even though newer ceramics have been formulated since the third-generation ceramic used in the original primary surgery, noise generation has persisted and continues to be of concern [
Fourth-generation ceramic-on-ceramic THA results in improvements in midterm outcomes compared to third-generation THA but does not resolve noise problems: a cohort study of a single-hip system.
]. However, the inertness of ceramics has been challenged by several studies. In a study by Lerouge et al., ceramic debris induced a granulomatous foreign body reaction that led to aseptic loosening [
The Stryker Accolade TMZF has a significant history of early failure and MACC, most notably due to trunnion corrosion, leading to a classic “bird-beak” wear pattern. There are many case reports in the literature that discuss early and catastrophic failure with the Accolade TMZF stem [
]. This could suggest that micromotion occurs and could lead to component wear. In this case, during a thorough investigation of the implants in a revision surgery, we found that the trunnion was intact with no signs of fretting or corrosion [
]. We feel that despite the TMZF’s history of trunnionosis, it was unlikely to be the cause of the ALTR in this case. However, due to the presence of a brown-stained fluid, there may have been a component of trunnion wear with local metal reaction and nanoparticle formation in the absence of obvious trunnion corrosion.
The histologic patterns seen in ALTR vary widely, which may be affected by the implant composition as well as the duration of implantation. Ricciardi et al. described 3 main categories in which cases of ALTR in hip implants fall: macrophage-dominant, mixed macrophagic and lymphocytic with or without an allergic or a hypersensitivity response, and granulomatous [
]. In this case, the histology seen can be categorized as a mixed macrophagic and lymphocytic response. The significance of this finding may be that we observe this type of response rather than a predominantly macrophagic one due to a lack of local nanoparticle infiltration, as is often seen with MoM ALTRs.
Acute neuropathy following a THA is not common with an incidence of 0.6% to 3.7% and most often involves the sciatic nerve [
]. Delayed-onset neuropathy is rare, and femoral nerve compression is almost nonexistent, especially from ALTRs. In a report by Fokter et al., there were only 3 cases of femoral nerve neuropathy resulting from MoM or MoP bearing debris [
]. A prompt revision arthroplasty is recommended with controversy over either complete excision or indirect decompression via debridement of the ALTR. Harvie et al. reported 2 cases of femoral neuropathy due to ALTRs from an MoM resurfacing arthroplasty [
]. Both cases resulted in revision arthroplasty and femoral nerve neurolysis.
This is the first reported case of an ALTR from a CoC bearing resulting in femoral nerve compression. The lack of backside liner wear, trunnion corrosion, and impingement, as well as normal levels of cobalt, chromium, and titanium, suggests that the ALTR was due to ceramic debris from the CoC bearing.
There are several limitations to the study. First, there was no preoperative aspiration performed, and thus, there was no preoperative histological evaluation. The surgeon did not think that aspiration was warranted given the diagnosis of ALTR using the magnetic resonance images and that infection was highly unlikely. Histological evaluation would have been helpful in identifying the type of ALTR and possibly the cause of its formation.
Summary
We present a case of femoral nerve compression from an ALTR in a patient with a ceramic-on ceramic bearing surface. The ALTR occurred with no source of metal debris and normal levels of cobalt, chromium, and titanium. This case reveals that the ceramic wear debris may not be completely inert and can lead to an ALTR and, in this case, femoral nerve compression.
Conflicts of interest
R. G. Gosthe is a paid consultant for Zimmer Biomet. All other authors declare no potential conflicts of interest.
The author(s) confirm that written informed consent has been obtained from the involved patient(s) or if appropriate from the parent, guardian, power of attorney of the involved patient(s); and, they have given approval for this information to be published in this case report (series).
Growth of an intrapelvic pseudotumor associated with a metal-on-metal total hip arthroplasty after revision arthroplasty causing a femoral nerve neuropathy.
Fourth-generation ceramic-on-ceramic THA results in improvements in midterm outcomes compared to third-generation THA but does not resolve noise problems: a cohort study of a single-hip system.
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